Patient assessment before using tumour necrosis factor alpha blockers in inflammatory bowel disease

Blokatori tumor-nekrotizirajućeg faktora alfa (TNF-α) biološki su agensi kojima se blokira ključni proupalni citokin u upalnim bolestima crijeva, stoga je biološka terapija postala jedna od najznačajnijih u liječenju tih bolesti. U Hrvatskoj su registrirana dva blokatora TNF-α: infliksimab (RemicadeR) i adalimumab (HumiraR). U radu su navedeni postupci koje je potrebno učiniti prije uporabe biološke terapije. Ti postupci uključuju iscrpne anamnestičke podatke o ranijim infektivnim bolestima i cijepljenju te detaljan klinički pregled radi isključivanja infekcije. Prisustvo apscesa te pogoršanje kolitisa uzrokovano Clostridium difficile toksinom ili Cytomegalovirus (CMV) infekcijom predstavljaju apsolutnu kontraindikaciju za uporabu blokatora TNF-α. Njihova je uporaba također kontraindicirana u bolesnika s popuštanjem srca NYCHA III ili IV. Oprez je potreban u bolesnika s kroničnim bolestima jetre, neurološkom patologijom te u bolesnika s ranijim malignim bolestima, posebno limfomima. Od laboratorijskih nalaza potrebno je učiniti: leukogram, diferencijalni leukogram, CD4 stanice u slučaju leukopenije, transaminaze, C-reaktivni protein (CRP), analizu urina, serologiju za hepatitis C virus (HCV), hepatitis B virus (HBV) i virus humane imunodeficijencije (HIV). Ovisno o anamnestičkim podacima potrebna je i serologija za varicella zoster virus (VZV). Broj eozinofila, pregled stolice i serologija na strongiloidijazu potrebni su u slučaju boravka u tropima. Nadalje je potrebno učiniti radiogram pluća, PPD i radioimunoesej za interferon gama (IGRA) (od engl. interferon gamma release assay) prema nacionalnim smjernicama, a radi isključivanja aktivne i latentne tuberkuloze. Cijepljenje živim cjepivom kontraindicirano je za vrijeme terapije blokatorima TNF-α. Prije započinjanja terapije potrebno je, u seronegativnih, cijepljenje protiv hepatitisa B, dok se cijepljenje protiv humanog papiloma virusa (HPV) i VZV-a provodi samo u specifičnim slučajevima. Neživo cjepivo za sezonsku gripu potrebno je bolesnicima aplicirati jednom godišnje, a pneumokokno cjepivo jednom u pet godina.Tumour necrosis factor alpha (TNF-α) blockers are biological agents that specifically target the key cytokine in the inflammatory bowel process and became almost the mainsty in the therapy of inflammatory bowel disease. Currently, there are two TNF-α blockers available for clinical use in Croatia: infliximab (RemicadeR), and adalimumab (HumiraR). This paper reviews the necessary investigations before using this drugs. Before using TNF-α blockers detailed interview with the history of previous infective diseases and vaccination is necessary. Clinical examination in order to exclude any infection is mandatory. In patients with abscess and with Clostridium difficile or Cytomegalovirus (CMV) superinfection, biological therapy is contraindicated. This therapy is also contraindicated in NYCHA III or IV cardiac insufficiency. It must be used with caution in patients with chronic liver disease, neurological pathology or history of malignancies, especially lymphoma. Laboratory tests include neutrophil and lymphocyte count, in the case of lymphopenia, CD4 lymphocyte count, transaminases, C-reactive protein (CRP), urine analysis, hepatitis C virus (HCV), hepatitis B virus (HBV) and human immunodeficiency virus (HIV) serology, varicella zoster virus (VZV) serology (in patients without a clear history of varicella immunisation). Eosinophil count, stool examination and strongyloidiasis serology for patients having lived in a tropical area. Furthermore, before treatment with anti TNF-α all patients should be checked both for active and for latent tuberculosis infection. This check include: chest X-ray, tuberculin skin test and interferon gamma release assay (IGRA), according to country-specific guidelines. Vaccination with live vaccines is contraindicated during treatment with biological agents. Hepatitis B vaccination should be administered in naive patients. Other vaccinations (varicella, human papilloma virus) should be proposed to specific patients. Influenza vaccine should be given annually and 23-valent pneumococcal vaccine every 5 years

ENTERAL FEEDING IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Uloga enteralne prehrane u liječenju kronične upalne bolesti crijeva još uvijek nije jasno definirana. U radu su prikazane posljedice malnutricije kao jednog od osnovnih simptoma kronične upalne bolesti crijeva te, sukladno tome, njihovo liječenje. Iz prikazanog jasna je potreba suportivne terapije adekvatnim enteralnim pripravcima. To se posebice odnosi na dječju populaciju oboljelih budući da poremećaj rasta i razvoja ima dalekosežne posljedice. Važnost potpune enteralne prehrane kao inicijalne terapije još nema adekvatnog odgovora i zahtijeva daljnje prospektivne analize. Prikazane su i neke nove mogu}nosti prehrane u liječenju kronične upalne bolesti crijeva, koje predstavljaju moguću budć}nost u terapiji tih bolestiThe purpose of enteral feeding in the inflammatory bowel diseases (IBD) has not been well defined yet. This article presents the consequences of malnutrition, as one of the basic symptoms of IBD and its therapy, respectively. As it is shown here, a supportive therapy with adequate enteral feeding is of great value, especially in pediatric patients due to long-term consequences of the growth failure and the failure to thrive. A complete enteral feeding as a primary and the only therapy in IBD has not been established completely yet and needs further analyses. We have shown some new ways of the enteral treatment of IBD that could be a future therapy of these illnesse

SCREENING FOR OPPORTUNISTIC INFECTIONS AND VACCINATION BEFORE INTRODUCTION OF BIOLOGIC THERAPY

Bolesnici koji primaju anti-TNF-α lijekove imaju povišeni rizik za oportunističke infekcije. Prije uvođenja terapije potreban je probir na: viruse hepatitisa, HIV, EBV, HPV, tuberkulozu, bakterijske i gljivične infekcije te parazite. Probir se sastoji od anamnestičkih podataka za ranije infektivne bolesti, ranija cijepljenja i putovanja u krajeve s endemskim bolestima. Klasični klinički pregled je potrebno nadopuniti stomatološkim i ginekološkim pregledom. Laboratorijski nalazi uključuju leukogram, aminotransferaze, Creaktivni protein, analizu urina i urinokulturu, serologiju na hepatitis B i C, HIV te EBV. Serologija za varicella zoster virus (VZV) ovisi o anamnestičkim podacima. U slučaju boravka u tropima potrebna je analiza stolice i serologija na strongiloidijazu. Od ostalih pregleda obvezan je radiogram pluća, PPD i serološka dijagnoza tuberkuloze testom IGRA (od engl. Interferon Gamma Release test). Kod sumnje na intraabdominalni apsces preporučuje se magnetska rezonancija abdomena. Prisustvo apscesa te pogoršanje kolitisa uzrokovano toksinom Clostridium difficile ili CMV infekcijom su apsolutna kontraindikacija za uporabu anti-TNF-α. Cijepljenje živim cjepivom je kontraindicirano u bolesnika na terapiji anti-TNF-lijekovima. Sve seronegativne bolesnike treba cijepiti cjepivom hepatitisa B. Cjepivo protiv sezonske gripe preporuča se aplicirati jednom godišnje, a 23-valentno pneumokokno cjepivo jednom u pet godina. Ovisno o anamenzi i serologiji bolesnike cijepimo VZV cjepivom uz poseban oprez, dok se cijepljenje protiv humanog papiloma virusa (HPV) provodi u žena do 23. godine života i nakon uzimanja cervikalnog brisa.Patients on anti-TNFmedications carry a higher risk for developing opportunistic infections. In order to introduce anti-TNFα therapy, screening for hepatitis viruses B and C, HIV, EBV, HPV, TBC, bacterial, fungal and parasitic infections should be performed. Screening involves patient’s history of earlier infectious diseases, vaccinations and traveling to parts of the world with endemic diseases. Clinical examination should be supplemented with stomatologic and gynecologic exams. Laboratory results include leukogram, transaminases, C-reactive protein, urine analysis, hepatitis B, C, HIV and EBV serology. Varicella zoster virus serology depends on past medical history. If the patient has traveled to tropical areas, both stool analysis and strongiloidiasis serology should be performed. Other mandatory examinations include chest radiography, PPD and TBC serology using interferon gamma release test (IGRA). If suspecting intra-abdominal abscess, magnetic resonance of the abdomen is recommended. In case of abscess, CMV or Clostridium difficile colitis anti-TNF-therapy is contraindicated. Live vaccine application is contraindicated in patients receiving anti-TNFtherapy. All seronegative patients should be vaccinated against hepatitis B virus. Seasonal flu vaccination is recommended to be applicated yearly and pneumococcal polysaccharide vaccine once in every five years. Based on the past medical history and serologic results, patients are vaccinated against VZV with extra precaution. Human papilloma virus vaccination is performed in a group of women under 23 years of age, after gathering cervical smear sample analysis

SCREENING FOR OPPORTUNISTIC INFECTIONS AND VACCINATION BEFORE INTRODUCTION OF BIOLOGIC THERAPY

Bolesnici koji primaju anti-TNF-α lijekove imaju povišeni rizik za oportunističke infekcije. Prije uvođenja terapije potreban je probir na: viruse hepatitisa, HIV, EBV, HPV, tuberkulozu, bakterijske i gljivične infekcije te parazite. Probir se sastoji od anamnestičkih podataka za ranije infektivne bolesti, ranija cijepljenja i putovanja u krajeve s endemskim bolestima. Klasični klinički pregled je potrebno nadopuniti stomatološkim i ginekološkim pregledom. Laboratorijski nalazi uključuju leukogram, aminotransferaze, Creaktivni protein, analizu urina i urinokulturu, serologiju na hepatitis B i C, HIV te EBV. Serologija za varicella zoster virus (VZV) ovisi o anamnestičkim podacima. U slučaju boravka u tropima potrebna je analiza stolice i serologija na strongiloidijazu. Od ostalih pregleda obvezan je radiogram pluća, PPD i serološka dijagnoza tuberkuloze testom IGRA (od engl. Interferon Gamma Release test). Kod sumnje na intraabdominalni apsces preporučuje se magnetska rezonancija abdomena. Prisustvo apscesa te pogoršanje kolitisa uzrokovano toksinom Clostridium difficile ili CMV infekcijom su apsolutna kontraindikacija za uporabu anti-TNF-α. Cijepljenje živim cjepivom je kontraindicirano u bolesnika na terapiji anti-TNF-lijekovima. Sve seronegativne bolesnike treba cijepiti cjepivom hepatitisa B. Cjepivo protiv sezonske gripe preporuča se aplicirati jednom godišnje, a 23-valentno pneumokokno cjepivo jednom u pet godina. Ovisno o anamenzi i serologiji bolesnike cijepimo VZV cjepivom uz poseban oprez, dok se cijepljenje protiv humanog papiloma virusa (HPV) provodi u žena do 23. godine života i nakon uzimanja cervikalnog brisa.Patients on anti-TNFmedications carry a higher risk for developing opportunistic infections. In order to introduce anti-TNFα therapy, screening for hepatitis viruses B and C, HIV, EBV, HPV, TBC, bacterial, fungal and parasitic infections should be performed. Screening involves patient’s history of earlier infectious diseases, vaccinations and traveling to parts of the world with endemic diseases. Clinical examination should be supplemented with stomatologic and gynecologic exams. Laboratory results include leukogram, transaminases, C-reactive protein, urine analysis, hepatitis B, C, HIV and EBV serology. Varicella zoster virus serology depends on past medical history. If the patient has traveled to tropical areas, both stool analysis and strongiloidiasis serology should be performed. Other mandatory examinations include chest radiography, PPD and TBC serology using interferon gamma release test (IGRA). If suspecting intra-abdominal abscess, magnetic resonance of the abdomen is recommended. In case of abscess, CMV or Clostridium difficile colitis anti-TNF-therapy is contraindicated. Live vaccine application is contraindicated in patients receiving anti-TNFtherapy. All seronegative patients should be vaccinated against hepatitis B virus. Seasonal flu vaccination is recommended to be applicated yearly and pneumococcal polysaccharide vaccine once in every five years. Based on the past medical history and serologic results, patients are vaccinated against VZV with extra precaution. Human papilloma virus vaccination is performed in a group of women under 23 years of age, after gathering cervical smear sample analysis

ENTERAL FEEDING IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Uloga enteralne prehrane u liječenju kronične upalne bolesti crijeva još uvijek nije jasno definirana. U radu su prikazane posljedice malnutricije kao jednog od osnovnih simptoma kronične upalne bolesti crijeva te, sukladno tome, njihovo liječenje. Iz prikazanog jasna je potreba suportivne terapije adekvatnim enteralnim pripravcima. To se posebice odnosi na dječju populaciju oboljelih budući da poremećaj rasta i razvoja ima dalekosežne posljedice. Važnost potpune enteralne prehrane kao inicijalne terapije još nema adekvatnog odgovora i zahtijeva daljnje prospektivne analize. Prikazane su i neke nove mogu}nosti prehrane u liječenju kronične upalne bolesti crijeva, koje predstavljaju moguću budć}nost u terapiji tih bolestiThe purpose of enteral feeding in the inflammatory bowel diseases (IBD) has not been well defined yet. This article presents the consequences of malnutrition, as one of the basic symptoms of IBD and its therapy, respectively. As it is shown here, a supportive therapy with adequate enteral feeding is of great value, especially in pediatric patients due to long-term consequences of the growth failure and the failure to thrive. A complete enteral feeding as a primary and the only therapy in IBD has not been established completely yet and needs further analyses. We have shown some new ways of the enteral treatment of IBD that could be a future therapy of these illnesse

Gluten-related disorders

Gluten je bjelančevina koja se nalazi u pšenici, dok se u raži, ječmu i zobi nalaze slične bjelančevine. Zajedničkim imenom one se nazivaju gluten i mogu uzrokovati više različitih poremećaja koji se dijele na autoimune, alergijske i neautoimune – nealergijske. Samo se celijakija pojavljuje u genetski predisponiranih osoba te se manifestira crijevnim, ali i brojnim izvancrijevnim manifestacijama. Važno je točno dijagnosticirati poremećaje povezane s glutenom jer je njihovo liječenje različito. Velik broj ljudi samoinicijativno se odlučuje za bezglutensku dijetu pod utjecajem popularne literature. No, na taj se način otežava postavljanje točne dijagnoze i odgovarajuće terapije.Gluten is a protein found in wheat, while similar proteins are present in rye, barley and oats. These proteins can cause many different disorders, classified as autoimmune, allergic, and non-autoimmune non-allergic. Only celiac disease can occur in genetically predisposed people, and it presents with a variety of both intestinal and extraintestinal manifestations. Early recognition of symptoms and diagnosis of gluten-related disorders is important for the adequate treatment. A large number of people decide to go on a gluten-free diet under the influence of popular literature. However, it makes much more difficult establish the accurate diagnosis and appropriate therapy

ASSESSMENT OF NUTRITIONAL RISKS IN HOSPITALISED PATIENTS

Otkrivanje pothranjenosti u bolesnika važan je zadatak jer pothranjenost utječe na morbiditet, mortalitet, dužinu hospitalizacije i troškove liječenja. Cilj rada bio je jednostavnim i brzim testom otkriti koliko se hospitaliziranih bolesnika nalazi u nutritivnom riziku. Ispitana su 843 bolesnika hospitalizirana na Klinici za internu medicinu lokaliteta Rijeke od 1. studenoga 2001. do 1. listopada 2003. Za procjenu nutritivnog rizika koristili smo Nottingham Screening Tool (NST) koji boduje indeks tjelesne mase (engl. body mass index – BMI), gubitak težine u zadnja tri mjeseca, uzimanje hrane mjesec dana prije hospitalizacije i težinu osnovne bolesti. Od ukupnog broja ispitanika, 48% se nije nalazilo u nutritivnom riziku, 27% je zahtijevalo praćenje i reevaluaciju, a 25% nutritivnu potporu. U skupini bolesnika s malignom bolešću, čak se 75% bolesnika nalazilo u nutritivnom riziku, što je statistički značajno češće (p<0, 001) u odnosu prema skupini nemalignih bolesnika. Dobiveni rezultati nalažu evaluaciju nutritivnog statusa pri prijemu u bolnicu jer adekvatnim tretmanom pothranjenosti možemo utjecati na tok i troškove liječenja.Revealing nutrition status in patients is an important task because malnutrition influences morbidity, mortality, the length of hospital stay and costs. The aim of the study was to find out how many hospitalised patients are at a nutritional risk, with a fast and simple test. We examined patients hospitalised at the Internal Clinic of the Clinical Hospital Centre Rijeka in the period from November 1st 2001 till October 1st 2003. To assess the nutritional risk we used the Nottingham Screening Tool (NST) which scores body mass index (BMI), recent body weight loss, food intake before the hospitalisation and the severity of illness. We examined 843 patients. Only 48% were not at nutritional risk, 27% demanded monitoring and re-evaluation, and 25% were referred to dietetic advice. Of those 23% with malignancies, 75% were at nutritional risk. In comparison with non-malignant patients, the result was statistically significant (p<0,001). There is a significant malnutrition risk in hospitalised patients, especially in malignant ones. NST is a fast and efficient test for assessing the malnutrition risk. Malnutrition has to be evaluated and treated with nutrition support measure

ASSESSMENT OF NUTRITIONAL RISKS IN HOSPITALISED PATIENTS

Otkrivanje pothranjenosti u bolesnika važan je zadatak jer pothranjenost utječe na morbiditet, mortalitet, dužinu hospitalizacije i troškove liječenja. Cilj rada bio je jednostavnim i brzim testom otkriti koliko se hospitaliziranih bolesnika nalazi u nutritivnom riziku. Ispitana su 843 bolesnika hospitalizirana na Klinici za internu medicinu lokaliteta Rijeke od 1. studenoga 2001. do 1. listopada 2003. Za procjenu nutritivnog rizika koristili smo Nottingham Screening Tool (NST) koji boduje indeks tjelesne mase (engl. body mass index – BMI), gubitak težine u zadnja tri mjeseca, uzimanje hrane mjesec dana prije hospitalizacije i težinu osnovne bolesti. Od ukupnog broja ispitanika, 48% se nije nalazilo u nutritivnom riziku, 27% je zahtijevalo praćenje i reevaluaciju, a 25% nutritivnu potporu. U skupini bolesnika s malignom bolešću, čak se 75% bolesnika nalazilo u nutritivnom riziku, što je statistički značajno češće (p<0, 001) u odnosu prema skupini nemalignih bolesnika. Dobiveni rezultati nalažu evaluaciju nutritivnog statusa pri prijemu u bolnicu jer adekvatnim tretmanom pothranjenosti možemo utjecati na tok i troškove liječenja.Revealing nutrition status in patients is an important task because malnutrition influences morbidity, mortality, the length of hospital stay and costs. The aim of the study was to find out how many hospitalised patients are at a nutritional risk, with a fast and simple test. We examined patients hospitalised at the Internal Clinic of the Clinical Hospital Centre Rijeka in the period from November 1st 2001 till October 1st 2003. To assess the nutritional risk we used the Nottingham Screening Tool (NST) which scores body mass index (BMI), recent body weight loss, food intake before the hospitalisation and the severity of illness. We examined 843 patients. Only 48% were not at nutritional risk, 27% demanded monitoring and re-evaluation, and 25% were referred to dietetic advice. Of those 23% with malignancies, 75% were at nutritional risk. In comparison with non-malignant patients, the result was statistically significant (p<0,001). There is a significant malnutrition risk in hospitalised patients, especially in malignant ones. NST is a fast and efficient test for assessing the malnutrition risk. Malnutrition has to be evaluated and treated with nutrition support measure

Gender Related Differences in Quality of Life and Affective Status in Patients with Inflammatory Bowel Disease

According to the literature, quality of life has been shown to be reduced in females compared with males with Inflamatory Bowel Disease (IBD). Psychosocial factors are also playing an important role in IBD, especially emotional lability. The aims of study was to investigate the sex differences in general and specific health-related quality of life (HRQoL), anxiety and depression in IBD patients. Hundred and twelve outpatients of the Gastroenterology Division, Clinical Hospital Centre Rijeka, were enrolled in our study and divided in two groups: 50 females (31 with ulcerative colitis,UC and 19 with Crohn disease, CD) and 62 males (30 with UC and 32 with CD), age range 19 to 74 (M=41.46; SD=13.06). Most patients have been in long clinical remission or with mild disease acording to Clinical Disease Activity Index (CDAI) score for CD and Clinical Activity Index (CAI) score for UC. There were significant differences in physical (F=13.96, p<.0001) and mental (F=9.44, p<.001) component of the general HRQoL, emotional domain ((F=9.26, p<.001) and bowel symptoms (F=7.04, p<.001) of the Inflamatory Bowel Disease Quality of life (IBDQoL), as well as, in anxiety (F=7.03, p<.001) and depression (F=12.09, p<.0001) between men and women with IBD. Women have expressed significantly lower level of the general HRQoL and more emotional disturbances connected with their disease as well as more frequent bowel symptoms compared with men. Effect sizes of those differences were large. Results of this study confirm that women with IBD are more prone to the negative impact of the disease on their HRQoL than men. Women with higher level of depression and anxiety experienced more emotional disturbances, bowel and systemic symptoms and lower general HRQoL. These results should deserve more considerations in the clinical treatment of IBD patients